GW1-2022-01638_Well Construction - GW1_20220201

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Sean Cropsey 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
2485-A ft ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable
Applied Resource Management FROM TO DIAMETER THICKNESS MATERIAL
ft ft, in.
Company Name
16.INNER CASING OR TUBING eother at closed-loop)
2.Well Construction Permit#: WC P-21-01224 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc) 170 ft. 150 ft. 4 tn' SCh 40 PVC
3.Well Use(check well use): 110 ft. ft' 4 in- Sch 40 PVC
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural QMunicipal/Public 150 ft. 110 ft. 4 in. 020 Sch 40 PVC
Geothermal(Heating/Cooling Supply) EoResidential Water Supply(single) ft. ft. in.
lndustrial/Commercial Residential Water Supply(shared) 18.GROUT
hrl ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply well: 170ft• 150ft• Bentonite Pour
Monitoring ORecovery 100 ft. 0.0 ft. Bentonite Pour
Injection Well: ft. ft.
Aquifer Recharge Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
DAquifer Storage and Recovery [:)Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
DAquifer Test QlStormwaterDrainage 150 ft. 100ft• #2 Pour
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) QlTracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION color,hardness,soil/rock e, rain size,etc.)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) 0 ft. 10 ft. Fine silty sand
4.Date Well(s)Completed: 1/18/2022 Well ID# 10 ft. 25 ft- light gray clay, fine sand, shell seams
5a.Well Location: 25 rt' 65 ft. Dark gray clay with fine sand lense's
Rhetson Company Dollar General-Whiteville 65 ft 110 ft. Gray clay with fine sand layers
Facility/Owner Name Facility ID#(if applicable) 110ft• 150 ft- Gray Limestone
77 Seven Creeks Hwy, Whiteville, NC 150ft• 170 ft- Dark gray clay, some sand
Physical Address,City,and Zip ft. ft.
Columbus 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
34 14 18.11 N 78 40 26.93 w ':3Q,a-'y (�3te 1/18/2022
6.Is(are)the well(s)0iPermanent or [3Temporary Signature of Certified Well Contraclwr Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: QYes or ®No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 170 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 20 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 8 (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: Mud Rotary construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 50 Method of test: Air Lift 24c.For Water Supply&Iniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: HTH Amount: completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016